Workplace Ergonomics Assessment Form
Employee Information
Name
Department
Position
Email
Assessment Date
Workstation Assessment
Workstation Location
Chair
Adjustable Height
Proper Lumbar Support
Stable Base
Desk
Sufficient Space
Appropriate Height
Monitor
Top at Eye Level
About Arm's Length Away
No Glare
Keyboard & Mouse
Within Easy Reach
Wrists Straight
Proper Support
Environmental Assessment
Lighting
Adequate Natural Light
No Glare
No Flicker
Temperature
Comfortable
No Drafts
Other Issues
Risk Factors
Discomfort
Pain
Frequent Reaching
Repetitive Movements
Awkward Postures
Other:
Recommendations / Actions
Recommendations
Assessor Information
Assessor Name
Date